Beating the 30 day readmission: Why there’s little to celebrate

It’s a statistic that keeps hospital administrators up at night. Whether you agree or disagree with the use of this statistic as a quality and reimbursement metric, if it creates change, reduces hospital re-admissions and improves patient care, then in theory I support it.

I’m reminded of Mrs G. She is emblematic of today’s chronic disease patient. She was admitted to our hospital for a congestive heart failure exacerbation, complicated by a COPD (related to her smoking) exacerbation. Throw in some poorly controlled diabetes, atrial fibrillation, depression and generalized deconditioning, this lovely 64 year old lady spent 9 days in our hospital receiving absolutely excellent care. She improved to the point where our terrific inpatient team was able to discharge her directly to home on Tuesday March 27th. From there she was in the hands of her 2 caring daughters and her outpatient doctors at my clinic. And that’s when the clock started ticking.

Tuesday April 3rd: Hospital follow-up. We were able to see her 7 days post-discharge. She was doing well, taking all her medications and her family seemed content with the current situation. Despite how well she was doing, we felt this was the type of patient who could easily decline. We scheduled another appointment in 1 week for further monitoring.

Friday April 6th: Some blood work results came back to our office. Her kidney function had steeply declined. We suspected the high doses of diuretics (water pills) she was taking were the reason. We contacted her over the phone, advised to reduce the doses of her medication and keep her next appointment. She expressed some frustration from constant thirst and generalized fatigue.

Wednesday April 11th: She seemed worse compared to the first visit. She was still thirsty and her legs appeared more swollen. She was also more short of breath. Her atrial fibrillation (irregular heart rhythm) was not controlled. We adjusted one of her 11 medications to try and counter this. One a side note, she insisted she wasn’t smoking anymore. We ordered more follow up blood work.

Monday April 16th: Her kidney function improved. We called her to discuss these results. She said she felt fine but then her daughter grabbed the phone and from a separate room, explained to us how she hasn’t been following any of our dietary recommendations, and continued to smoke daily while on oxygen! Her family asked us to see her again to bring up these issues at the next appointment.

Friday April 20th: She vehemently denied smoking and drinking excessive fluids, despite having worsening leg swelling and smelling of cigarettes. We increased her water pills back to her prior dose, realizing she had re-accumulated fluid. It was only a matter of time before the fluids got into her lung and she became short of breath again. She was headed in the wrong direction.

For her next appointment, she came to our office looking absolutely terrible. She couldn’t breathe well, lie flat and her legs were even more swollen. She had been to a barbecue over the weekend and ate salt ridden food without much thought. She had declined to the point where it was no longer safe to try to mange her in the clinic. It was time to head back to the hospital. She shook her head out of frustration as her daughter welled up with tears in the corner of the exam room. Mrs. G asked me if I thought she’d miss Mothers day.

I looked at the calendar and I said probably not. If things went according to plan, I anticipated a short hospital stay. A midst her breathlessness, I sensed some relief in her.

Once I realized what day it was, I too breathed a sigh of relief. It was Monday April 30th.

She was discharged on March 27th. And so I counted 7… 14 … 23 … 33 days had elapsed. She had eclipsed the 30 day readmission window. My first inclination was to pat myself on the back and hang up a mental banner with the words “Mission Accomplished.” But as I saw Mrs. G getting wheeled away on a stretcher and her distraught daughter trailing behind. I felt very little desire to celebrate having reached this important 30 day benchmark.

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NewMexicoRam

Yep. Everyone is financially responsible but the patient. Really doesn’t make any sense.

Ginger

She probably would have been back sooner if the hospital hadn’t monitored her. I would think that over time, with the proper “nagging” that the patient and her caregivers might get better at self-monitoring and the frequency of crisises would diminish. It’s progress, not perfection!

Patients with reduced physiologic reserve and chronic disease who do not follow instructions end up sick again and sooner. The whole bounce back tracking and regulations only makes sense if the tracking shows that systems processes result in a poor outcome. If the system process is individual behavior choices then the institution should not be held responsible. Unfortunately, in todays world the regulators and bureaucrats are in a position where caring and concerned caregivers and institutions do not have the guts and or resources to take them on and challenge regulations that are insane. Ultimately this comes down again to individuals not taking responsibility for their actions and it being someone else’s fault

christythomas

The lack of patient compliance here really bothers me–and I am not a physician. I know how difficult it is to eat properly and engage in good self-care habits, but it is hardly impossible. It is not the physican’s job to make her personal decisions for her. But this is part of our whole ethos–let a pill fix it rather than the far more effective healing methods of careful diet, sunshine, good rest, and adequate movement. So we just get sicker and sicker, and expect some outside force to fix problems that we very much bring on ourselves.